Provider First Line Business Practice Location Address:
390 SOUTH 3RD WEST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SODA SPRINGS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83276
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-547-2220
Provider Business Practice Location Address Fax Number:
208-547-2224
Provider Enumeration Date:
10/20/2005